Comparing Perspectives of Patients, Caregivers, and Clinicians on Heart Failure Management

Gaps in care delivery for patients with heart failure: A qualitative study of patients with multiple readmissions

BACKGROUND

Despite significant advances in the management of patients with heart failure with preserved and reduced ejection fraction (HFpEF and HFrEF), readmission rates remain high.

OBJECTIVES

In this study, we sought to understand the experiences and gaps in care delivery among heart failure (HF) patients with multiple readmissions.

METHODS

We conducted a qualitative study using semistructured interviews with patients admitted with HF exacerbation and who had a prior admission for HF exacerbation within 1 year of the interview. We analyzed the interview contents using thematic analysis. Additionally, we reviewed the medical charts and collected information regarding patients' disease course and treatments.

RESULTS

Our study included 24 patients, 54% had HFrEF, and 46% had HFpEF. Two major themes emerged; the first theme was centered on hospital readmissions, which often uncovered gaps in communication and deficiencies in discharge education. Patients expressed frustration with recurrent admissions, identified communication challenges while inpatient, and highlighted the shortcomings of the current discharge education models. The second theme explored the ways in which fragmented understanding of HF as a result of gaps in effective care delivery impacted multiple domains of care spanning the spectrum from initial diagnosis to prognosis. The interviews highlighted important differences between patients with HFrEF and HFpEF.

CONCLUSIONS

Patients with HF and recurrent admissions shared multiple gaps in care delivery with important differences noted between HFpEF and HFrEF patients. These findings can inform the design of future targeted interventions to ensure effective care delivery to a high-risk population.

Examining Heart Failure Informal Care Partners Using Person and System Levels and Domains: A Meta-Synthesis

BACKGROUND

Within the last decade, system and policy-level changes have driven substantial shifts in heart failure (HF) care from hospital to home, requiring greater support from informal care partners. What has not been examined is the state of the care partner science by person and system-level domains using qualitative studies to understand impact across multiple person and system levels.

OBJECTIVES

(1) Identify by person and system levels and domain what is known about informal care partners and (2) Identify gaps in the caregiving science and suggest ways to move forward.

METHODS

This secondary analysis of a large HF systematic review is guided by the National Institute on Minority Health and Health Disparities and MIRACLE frameworks and uses meta-synthesis techniques with critical realist approaches to synthesize and interpret the themes across papers.

RESULTS

Using data from 46 papers and 1695 care partners, we identified patterns occurring across 6 domains (biological, behavioral, affective, physical/built environment, sociocultural environment, and healthcare system) and on 4 levels (individual, interpersonal, community, and societal). Existing research predominantly addressed affective and behavioral domains, followed by health system and sociocultural domains. Few studies focused on biological and physical/built environment domains, leaving large gaps in what is known about caregiving at the cellular (biological) and societal (community and societal) levels.

CONCLUSIONS

HF caregiving continues to be studied at a very rudimentary level. This synthesis also reveals critical gaps in what is known about caregiving within the physical/built environment domain and at the community and societal levels.

Evaluating dyadic factors associated with self-care in patients with heart failure and their family caregivers: Using an Actor-Partner Interdependence Model

Dyadic conditions of patients with heart failure and their caregivers may affect both patient self-care and caregiver contribution to patient self-care (CCPS). The purpose of this study was to examine the relationships of patient-caregiver physical function and depressive symptoms to the patient self-care (maintenance and management) and CCPS. Data from 55 were analyzed using an Actor-Partner Interdependence Model to address the aim through AMOS. Patient self-care was very poor. Better patient physical function was related to better patient self-care management (actor effect) and poorer CCPS maintenance (partner effect). Better caregiver physical function was related to CCPS management (actor effect). Severer patient depressive symptoms were related to poorer patient self-care maintenance (actor effect) and poorer CCPS management (partner effect). Physical function and depressive symptoms in patient-caregiver dyads were related to patient self-care and CCPS. To improve patient self-care and CCPS, dyadic support for physical function and depressive symptoms is needed.

Knowing the Patient: Understanding Readmission Reasons in Complex Heart Failure

BACKGROUND

Heart failure (HF) is a complex problem characterized by frequent hospitalizations and high 30-day readmission rates. Researchers studying HF readmission report that patients and clinicians have different perspectives on readmission and preventability when unadjusted for disease severity.

OBJECTIVE

The aim of this study was to gather patient, caregiver, nurse, and physician subjective reason(s) for 30-day HF readmission and perceptions of preventability with contextual factors to evaluate differences.

METHODS

A convergent, parallel, mixed-methods design was used with interviews and chart reviews to evaluate contextual factors from the current and index hospital stay. Adults readmitted within 30 days of a previous inpatient stay with a coded HF diagnosis were enrolled and interviewed, followed by interviews with associated caregivers, attending physicians, and assigned nurses.

RESULTS

Interviews were conducted with patients (n = 44), caregivers (n = 6), physicians (n = 24), and nurses (n = 44). Readmissions were emergent/urgent (95%) and occurred within 14.9 days (SD, 8.1; 2-28 days) on average after discharge. Index stay coding revealed that most patients (73%) had a high severity of illness (73%) and risk of mortality (68%). Heart failure stage was inconsistently documented. Patients reported acute symptomatic reasons, with only 32% describing readmission as preventable. Physicians reported diagnostic reasons, 38% of which were preventable. Nurses reported behavioral reasons, with 59% being preventable. Patient/clinician agreement on readmission reason was low (30%).

CONCLUSIONS

Patient/clinician perspectives on readmission varied among the patients with complex HF. Care planning based on HF stage and other contextual factors is needed to ensure a shared understanding of disease severity and a tailored symptom management approach to prevent readmission.

Caregivers' Contributions to Heart Failure Self-care: An Updated Systematic Review

BACKGROUND

A previous systematic review reporting the contributions of informal, unpaid caregivers to patient heart failure (HF) self-care requires updating to better inform research, practice, and policy.

OBJECTIVE

The aim of this study was to provide an updated review answering the questions: (1) What specific activities do informal caregivers of adults with HF take part in related to HF self-care? (2) Have the activities that informal caregivers of adults with HF take part in related to HF self-care changed over time? (3) What are the gaps in the science?

METHODS

This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, CINAHL, EMBASE, and Cochrane CENTRAL databases were searched. Eligible studies involved an informal, unpaid caregiver of an adult with HF as a study variable or participant. Caregiving activities were benchmarked using the theory of self-care in chronic illness.

RESULTS

Two thousand one hundred fifty-four research reports were identified, of which 64 met criteria. Caregivers' contributions occurred in self-care maintenance (91%), monitoring (54%), and management (46%). Activities performed directly on or to the patient were reported more frequently than activities performed for the patient. Change over time involved the 3 domains differentially. Gaps include ambiguous self-care activity descriptions, inadequate caregiving time quantification, and underrepresented self-care monitoring, supportive, and communication activities.

CONCLUSIONS

Newly identified caregiver-reported activities support updating the theory of self-care in chronic illness to include activities currently considered ancillary to HF self-care. Identified gaps highlight the need to define specific caregiving activities, determine task difficulty and burden, and identify caregiver self-care strategy and education needs. Exposing the hidden work of caregiving is essential to inform policy and practice.

Why Acute Undernutrition? A Qualitative Exploration of Food Preferences, Perceptions and Factors Underlying Diet in Adolescent Girls in Rural Communities in Nigeria

BACKGROUND

Adolescent girls are nutritionally vulnerable due to their rapid growth and increased nutrient requirements. Nigeria has the sixth-largest population in the world. This study qualitatively explored the food preferences, perceptions of nutritive value and factors underlying food consumption of adolescent girls in rural communities in Nigeria.

METHODS

The data were collected via the free listing of foods and focus group sessions conducted in the Hausa language with 48 unmarried adolescent girls. The discussions were audio-recorded, transcribed, translated into English, and analyzed using a deductive thematic framework.

RESULTS

The mean age of the respondents was 13.0 ± 2.7, and almost half (48%) had a primary school education. A total of 19 and 23 foods were identified as preferred, and perceived as nourishing, respectively. The top 10 foods present on both free lists overlapped considerably in terms of cognitive salience. The focus group themes included nutrition knowledge, food preferences, autonomy, household food allocation, courtship practices, and agricultural landscapes and economic access. The participants had minimal knowledge of nutrients and food groups, and their preferred foods were limited in diversity. The key factors in food preferences were desirable health effects, sensory attributes, and the contribution of foods to a desirable body image for marriage. Household food choices depended on parents. Thus, a desire for independence was an incentive for early marriage, mostly at 13 to 17 years. Gender inequities in household food distribution (quantity) and animal protein intake were reported. The participants believed that boys need more food for strength to impregnate girls. As part of a courtship practice, the girls received gifts of animal source foods from potential suitors. The food options were limited by financial challenges and low agricultural diversity.

CONCLUSION

To interrupt the cycle of inadequate food consumption and undernutrition in these adolescent girls, policy makers need to promote nutrition education and address the underlying determinants of inequitable access to nutritious foods.

Freelisting: A Technique for Enhancing the Community Health Needs Assessment

US health systems are required to conduct community health needs assessments (CHNAs). These assessments often rely solely on publicly reported disease prevalence data. The objective of this study was to identify a feasible qualitative method that can be implemented into CHNAs to confirm existing information and enhance them with new data and community narrative. Freelisting interviews were conducted in 2017 throughout a county in Pennsylvania. Individuals listed (1) things that improve health, (2) health problems, and (3) health barriers. Responses were grouped into like terms, Smith's salience index was calculated for each, subgroup variation was assessed. Community-reported health priorities were identified by salient terms juxtaposed with publicly reported disease prevalence data. 98 respondents throughout the county participated in freelisting interviews. Demographics resembled the population: median age 55, 46% female, 88% Caucasian, 9% uninsured. Salient terms that improve health included: "physical activity", "healthy eating", and "health services". Salient terms describing health problems included: "cardiovascular disease" and "spine and joint disease". Centers for Disease Control and Prevention (CDC)-reported chronic disease prevalence in the county included heart disease mortality (22% of deaths) and arthritis (26% of adults). Salient barriers to health included: "weight, physical activity, and dietary concerns", as well as "occupational concerns". This is in line with 2017 County Health Rankings related to obesity (reported 29%), however, while 10% were uninsured in the community, this was not a salient term. Freelisting can augment and inform CHNAs. In this single-county study, freelisting responses supported publicly available disease/mortality prevalence data and provided insight into community perceptions of health issues.

[Palliative care needs of heart failure patients: A mixed-method studyNecessidades de cuidados paliativos de pacientes com insuficiencia cardíaca: um estudo misto]

Introduction

The presence of physical, psychosocial, and spiritual signs and symptoms should be identified and managed through the palliative care that health care teams and professionals pro vide.

Objective

To identify the palliative care needs of people with heart failure, their caregivers, and the multidisciplinary team of a heart failure unit.

Materials and Methods

A mixed-method study with a sequential transformative design (DITRAS, for its acronym in Spanish) was conducted. It began with a quantitative phase in which the Edmonton Symptom Assessment Scale (ESAS), the Therapy-Spiritual Well-Being Scale (FACIT-Sp-12), and the Barthel Index were used. The qualitative phase was conducted with three focus groups involving seven patients, eight caregivers, and twelve health professionals from the multidisciplinary team. Elizabeth Lenz's Theory of Unpleasant Symptoms was used as a guideline for this study.

Results

Physiological (edema, fatigue, and dyspnea) and psychological (attitude towards life and enjoyment of hobbies) palliative care needs and situational factors (caregiver dependence and support networks) were identified and could be understood through Lenz's theory.

Conclusions

Palliative care needs in patients with heart failure are presented under a framework of symptoms that patients, caregivers, and the health care team perceive. Comprehensive approaches are required to improve symptom experience.

Patient, caregiving partner, and clinician recommendations for improving heart failure care in the Veterans Health Administration

OBJECTIVE

Heart Failure (HF) care requires substantial care coordination between patients, patients' informal caregivers, and clinicians, but few studies have examined recommendations from all three perspectives. The objective of this study was to understand and identify shared recommendations to improve HF self-care from the perspective of VA persons with HF, their caregiving partners, and clinicians.

METHODS

Secondary data analysis from a study of semi-structured interviews with 16 couples (persons with HF and their caregiving partners) and 13 clinicians (physicians, nurses, other specialists) from a large Veterans Affairs (VA) hospital. Interviews were double-coded, and analyzed for themes around commonly used or recommended self-care strategies.

RESULTS

Three themes emerged: (1) Couples and clinicians believe that improvements are still needed to existing HF education, especially the need to be tailored to learning style and culture, (2) Couples and clinicians believe that technology can facilitate better HF self-care, and (3) Couples and clinicians believe that caregiving partners are part of the self-care team, and should be involved in care management to support the person with HF.

DISCUSSION

Recommendations from couples and clinicians address barriers to HF self-care and encourage patient-centered care.

Protocol for integrating mental health services into primary healthcare facilities: a qualitative study of the perspectives of patients, family members and healthcare providers in rural Bangladesh

INTRODUCTION

In Bangladesh, Non-communicable diseases (NCDs) account for 67% of all deaths. Mental health services are not available in routine healthcare at the primary facilities in Bangladesh. The protocol is for a qualitative study that seeks to understand the perceptions, beliefs and norms regarding common mental disorders (CMDs) among patients with NCD with and without CMDs to identify barriers to accessing mental health services in rural communities in Bangladesh. We also aim to explore the feasibility of integrating mental healthcare into routine NCD services at primary health facilities in rural Bangladesh.

METHODS AND ANALYSIS

This study will be conducted at the outpatient departments in two subdistrict hospitals and one district hospital in Munshiganj district in Bangladesh. We will purposefully select patients with hypertension and diabetes from the patient inventory generated from a recently completed randomised control trial titled 'Control of Blood Pressure and Risk Attenuation Bangladesh, Pakistan, Sri Lanka' in two subdistricts in Munshiganj district in Bangladesh. The selected participants will be screened for CMD using the Depression, Anxiety and Stress Scale - 21 Items (DASS-21) over the telephone. Sixty in-depth interviews with patients and family members, 8-10 key informant interviews with healthcare providers and 2 focus group discussions with community health workers will be held following consent.The study is conceptualised under Levesque et al's framework. Thematic analysis will be applied following the study objectives and key issues, and commonly emerging topics generated by the data. The findings will be presented anonymously to corroborate the interpretation.

ETHICS AND DISSEMINATION

Approval has been obtained from the Institutional Review Board at icddr,b (PR-19108) and the University of York (HSRGC/2020/382/F). Written informed consent or audio recording consent form in Bangla will be obtained. For dissemination, we will invite representatives of the collaborating institutions to share the findings in national or international conferences and peer-reviewed journals.

Do chronic heart failure symptoms interact with burden of treatment? Qualitative literature systematic review

OBJECTIVE

Explore the interaction between patient experienced symptoms and burden of treatment (BoT) theory in chronic heart failure (CHF). BoT explains how dynamic patient workload (self-care) and their capacity (elements influencing capability), impacts on patients' experience of illness.

DESIGN

Review of qualitative research studies.

DATA SOURCES

CINAHL, EMBASE, MEDLINE, PsycINFO, Scopus and Web of Science were searched between January 2007 and 2020.

ELIGIBILITY CRITERIA

Journal articles in English, reporting qualitative studies on lived experience of CHF.

RESULTS

35 articles identified related to the lived experience of 720 patients with CHF. Symptoms with physical and emotional characteristics were identified with breathlessness, weakness, despair and anxiety most prevalent. Identifying symptoms' interaction with BoT framework identified three themes: (1) Symptoms appear to infrequently drive patients to engage in self-care (9.2% of codes), (2) symptoms appear to impede (70.5% of codes) and (3) symptoms form barriers to self-care engagement (20.3% of codes). Symptoms increase illness workload, making completing tasks more difficult; simultaneously, symptoms alter a patient's capacity, through a reduction in their individual capabilities and willingness to access external resources (ie, hospitals) often with devasting impact on patients' lives.

CONCLUSIONS

Symptoms appear to be integral in the patient experience of CHF and BoT, predominately acting to impede patients' efforts to engage in self-care. Symptoms alter illness workload, increasing complexity and hardship. Patients' capacity is reduced by symptoms, in what they can do and their willingness to ask for help. Symptoms can lower their perceived self-value and roles within society. Symptoms appear to erode a patient's agency, decreasing self-value and generalised physical deconditioning leading to affective paralysis towards self-care regimens. Together describing a state of overwhelming BoT which is thought to be a contributor to poor engagement in self-care and may provide new insights into the perceived poor adherence to self-care in the CHF population.

PROSPERO REGISTRATION NUMBER

CRD42017077487.

An Assessment of Patient, Caregiver, and Clinician Perspectives on the Post-discharge Phase of Care

OBJECTIVE

We sought to elicit patients', caregivers', and health care providers' perceptions of home recovery to inform care personalization in the learning health system.

SUMMARY BACKGROUND DATA

Postsurgical care has shifted from the hospital into the home. Daily care responsibilities fall to patients and their caregivers, yet stakeholder concerns in these heterogeneous environments, especially as they relate to racial inequities, are poorly understood.

METHODS

Surgical oncology patients, caregivers, and clinicians participated in freelisting; an open-ended interviewing technique used to identify essential elements of a domain. Within 2 weeks after discharge, participants were queried on 5 domains: home independence, social support, pain control, immediate, and overall surgical impact. Salience indices, measures of the most important words of interest, were calculated using Anthropac by domain and group.

RESULTS

Forty patients [20 whites and 20 African-Americans (AAs)], 30 caregivers (17 whites and 13 AAs), and 20 providers (8 residents, 4 nurses, 4 nurse practitioners, and 4 attending surgeons) were interviewed. Patients and caregivers attended to the personal recovery experience, whereas providers described activities and individuals associated with recovery. All groups defined surgery as life-changing, with providers and caregivers discussing financial and mortality concerns. Patients shared similar thoughts about social support and self-care ability by race, whereas AA patients described heterogeneous pain management and more hopeful recovery perceptions. AA caregivers expressed more positive responses than white caregivers.

CONCLUSIONS

Patients live the day-to-day of recovery, whereas caregivers and clinicians also contemplate more expansive concerns. Incorporating relevant perceptions into traditional clinical outcomes and concepts could enhance the surgical experience for all stakeholders.

Readmitted Patients With Heart Failure Sick, Tired, and Symptomatic: A Qualitative Descriptive Study From a Quaternary Academic Medical Center

BACKGROUND AND OBJECTIVE

Heart failure (HF) readmissions will continue to grow unless we have a better understanding of why patients with HF are readmitted. Our purpose was to gain an understanding, from the patients' perspective, of how patients with HF viewed their discharge instructions and how they felt when they got home and were then readmitted in less than 30 days.

METHODS AND RESULTS

We used a qualitative descriptive approach using semistructured interviews with 22 patients with HF. Most participants had multimorbidities, were classified as New York Heart Association class III (n = 13) with reduced ejection fraction (n = 20), and were on home inotrope therapy (n = 13). The overarching theme that emerged was that these participants were sick, tired, and symptomatic. Additional categories within this theme highlight discharge instructions as being clear and easily understood; rich descriptions of physical, emotional, and other symptoms leading up to readmission; and reports of daily activities including what "good" and "not good" days looked like. Moreover, when participants experienced an exacerbation of their HF symptoms, they were sick enough to be readmitted to the hospital.

CONCLUSION

Our findings confirm ongoing challenges with a complex group of sick patients with HF, with the majority on home inotropes with reduced ejection fraction, who developed an unavoidable progression of their illness and subsequent hospital readmission.

Practical Guidance for Studies Using Freelisting Interviews

Freelisting is a qualitative interviewing technique that has recently grown in popularity. It is an excellent tool for rapidly exploring how groups of people think about and define a particular health-related domain and is well suited for engaging communities and identifying shared priorities. In this article, we outline 7 practical considerations for conducting freelisting studies summarized from 16 articles conducted by the authors at the University of Pennsylvania and Thomas Jefferson University in partnership with community-based organizations and students. Our recommendations can inform study design, data collection, and data analysis for investigators who are interested in using freelisting interviews in their research.

PRADOC: a trial on the efficiency of a transition care management plan for hospitalized patients with heart failure in France

Aims

Transition care programmes are designed to improve coordination of care between hospital and home. For heart failure patients, meta‐analyses show a high efficacy but with moderate evidence level. Moreover, difficulties for implementation of such programmes limit their extrapolation.

Methods and results

We designed a mixed‐method study to assess the implementation of the PRADO‐IC, a nationwide transition programme that aims to be offered to every patient with heart failure in France. This programme consists essentially in an administrative assistance to schedule follow‐up visits and in a nurse follow‐up during 2 to 6 months and aims to reduce the annual heart failure readmission rate by 30%. This study assessed three quantitative aims: the cost to avoid a readmission for heart failure within 1 year (primary aim, intended sample size 404 patients), clinical care pathways, and system economic outcomes; and two qualitative aims: perceived problems and benefits of the PRADO‐IC. All analyses will be gathered at the end of study for a joint interpretation. Strengths of this study design are the randomized controlled design, the population included in six centres with low motivation bias, the primary efficiency analysis, the secondary efficacy analyses on care pathway and clinical outcomes, and the joint qualitative analysis. Limits are the heterogeneity of centres and of intervention in a control group and parallel development of other new therapeutic interventions in this field.

Conclusions

The results of this study may help decision‐makers to support an administratively managed transition programme.

Views From Patients With Cancer in the Setting of Unplanned Acute Care: Informing Approaches to Reduce Health Care Utilization

PURPOSE

New oncology care delivery models that avoid preventable acute care are needed, yet it is unclear which interventions best meet the needs of patients and caregivers. Perspectives from patients who experienced unplanned acute care events may inform the successful development and implementation of care delivery models.

METHODS

We performed a qualitative interview study of patients with solid tumors on active treatment who experienced the following 3 types of unplanned acute care events: emergency department visits, first hospitalizations, and multiple hospitalizations. Patients were prospectively recruited within a large academic health system from August 2018 to January 2019. Interviews followed a semi-structured guide developed from the Consolidated Framework for Implementation Research. The constant comparative approach was used to identify themes.

RESULTS

Forty-nine patients were interviewed; 51% were men, 75% were non-Hispanic White, and the mean age was 57.4 years (standard deviation, 1.9 years). Fifty-five percent of patients had metastatic disease, and 33% had an Eastern Cooperative Oncology Group performance status of 3-4. We identified the following key themes: drivers of the decision to seek acute care, patients' emotional concerns that influence interactions with the oncology team, and strategies used to avoid acute care. Patients' recommendations for interventions included anticipatory guidance, peer support, improved triage methods, and enhanced symptom management. Patients preferred options for virtual and home-based outpatient care.

CONCLUSION

Patient-centered care models should focus on early delivery of supportive interventions that help patients and caregivers navigate the unexpected issues that come with cancer treatment. Patients advocate for proactive, multidisciplinary supportive interventions that enable home-based care and are led by the primary oncology team.

Effects of illness representation-focused patient education on illness representations and self-care in patients with heart failure: A randomised clinical trial

AIMS AND OBJECTIVES

To examine the effect of an illness representation-focused patient education intervention on illness representations and self-care behaviours in patients with heart failure 3 months after discharge from the hospital.

BACKGROUND

Few intervention studies have examined the effect of illness representation-focused interventions on illness representations and self-care in patients with heart failure.

DESIGN

A randomised clinical trial based on the Consolidated Standard of Reporting Trials-CONSORT 2010-guidelines was employed. The Clinical Trial Registry number is TCTR20190903002.

METHODS

One hundred and seven participants were randomly assigned to 2 groups, and 62 participants (n = 30 in the intervention group and n = 32 in the usual care group) completed the baseline and one- and three-month postdischarge follow-up assessments. The instruments included the Survey of Illness Beliefs in Heart Failure and the Self-care of Heart Failure Index. The intervention group received illness representation-focused patient education while hospitalised and telephone follow-ups after discharge. Data were analysed with linear mixed-effects model analysis.

RESULTS

The 107 participants had a mean age of 62.17 years and a mean left ventricular ejection of 53.03%. At baseline, the two groups tended to have accurate illness beliefs but insufficient self-care confidence and self-care maintenance. The analysis showed no significant differences between groups in the illness representation total scores, dimension scores or self-care maintenance scores but did show a significant difference in the self-care confidence scores (F = 3.42, p < .05) over the three months.

CONCLUSION

The study did not show an effect of the intervention on illness representations or self-care maintenance behaviours. However, the intervention did maintain participants' self-care confidence three months after discharge.

RELEVANCE TO CLINICAL PRACTICE

It is necessary to conduct long-term follow-ups of patients' illness representations, discuss the implementation of self-care behaviours with patients, enhance patients' self-care confidence, and involve family members or caregivers in self-care practices when needed.

Factors Associated With Predischarge Versus Postdischarge Scheduling for Early Follow-up Appointments

BACKGROUND

Per national guidelines, early follow-up appointments should be scheduled before discharge, but in previous research, appointments scheduled before discharge were not associated with appointment adherence.

OBJECTIVES

The purpose of this study was to determine whether patient, heart failure (HF), and hospital factors were associated with predischarge appointment scheduling.

METHODS

A secondary analysis of a medical record review included patients hospitalized for decompensated HF at 3 health system hospitals who had a scheduled office appointment post discharge at 14 days or less. Patient demographics, and social, HF, and hospital factors were studied for association with predischarge scheduling.

RESULTS

In multivariable modeling, the odds of having an appointment scheduled predischarge were based on 3 factors: nonwhite race, history of chronic renal insufficiency, and no admission within 14 days before HF hospitalization.

CONCLUSIONS

Appointment scheduling may be based on provider perceptions of readmission risk. Follow-up appointment scheduling practices should be based on systematic processes.

Symptom Management and Hospital Readmission in Heart Failure Patients: A Qualitative Study From Portugal

This article reports a study aimed at identifying the factors that result in hospital readmissions for patients with heart failure. The high rates of readmission are often due to a lack of knowledge about symptoms and signs of disease progression, and these Portuguese nurses believed that readmissions could be decreased through disease management programs in which patients assumed a more active role in self-care. A study was designed to identify broad categories of problems that lead Portuguese patients with heart failure to be readmitted to hospital. Semistructured interviews were conducted, recorded, and submitted for content analysis, revealing 3 main categories for targeting: health management, behavioral management, and psychological support. This study revealed that patients with heart failure seem to struggle with management of multiple treatment regimens during the long course of their chronic illness. Based on these interviews, authors conclude that a disease management program be tailored expressly for the Portuguese culture and their lifestyle.

Racial Differences in Perceptions of Psoriasis Therapies: Implications for Racial Disparities in Psoriasis Treatment

In the United States, black patients are less likely than white patients to receive biologic treatment for their psoriasis. We conducted a qualitative free-listing study to identify patient-generated factors that may explain this apparent racial disparity in psoriasis treatment by comparing the perceptions of biologics and other psoriasis therapies between white and black adults with psoriasis. Participants included 68 white and black adults with moderate to severe psoriasis who had and had not received biologic treatment. Each participant was asked to list words in response to verbal probes querying five psoriasis treatments: self-injectable biologics, infliximab, methotrexate, apremilast, and phototherapy. Salience scores indicating the relative importance of each word were calculated, and salient words were compared across each race/treatment group. Participants who had experience with biologics generally associated positive words with self-injectable biologics. Among biologic-naïve participants, "apprehension," "side effects," and "immune suppression" were most salient. "Unfamiliar" and "dislike needles" were salient only among black participants who were biologic naïve. Participants were generally unfamiliar with the other psoriasis therapies except phototherapy. Unfamiliarity with biologics, particularly among black, biologic-naïve patients, may partly explain the existing racial disparity in biologic treatment for psoriasis and might stem from lack of exposure to or poor understanding of biologics.

Patients’ Beliefs About Causes and Consequences of Heart Failure Symptoms

Patients’ perceptions of the causes and consequences of heart failure (HF) symptoms may impact effective self-management. The purpose of this study was to describe and explore patients’ perceptions of HF symptom status and the causes and consequences on their daily lives in patients with HF. Descriptive and qualitative data were obtained from 20 patients using a semistructured interview guide. Data were analyzed using content analysis and descriptive statistics. Participants reported 15 symptoms (median = 4). Five themes were (a) multiple causes and multiple symptoms; (b) knowing some causes, but still unclear; (c) not being able to live life as previously did; (d) facing emotional distress due to HF symptoms; and (e) development of new priorities and lifestyles. The findings demonstrate that all participants perceived considerable difficulties living with HF symptoms. More comprehensive interventions need to be delivered to patients to manage multiple causes and symptoms effectively.

Empowerment from patient's and caregiver's perspective in cancer care

The caregivers’ perceptions of the patients’ health condition may be biased and induce them to perceive higher needs than patients actually disclose. Our aim was to assess if the level of knowledge and awareness about cancer disease and treatment, and patient participation and assistance differs between caregivers and patients. A descriptive, cross-sectional study was conducted across five countries (Italy, United Kingdom, Spain, France and Germany) on a total of 510 participants who directly (patient) or indirectly (caregiver) faced a cancer diagnosis. Investigating this divergence could help to identify possible difficulties in patient–caregiver relationship, eventually improving patient empowerment.

Heart Failure Home Management Challenges and Reasons for Readmission: a Qualitative Study to Understand the Patient's Perspective

BACKGROUND

Heart failure patients have high 30-day hospital readmission rates. Interventions designed to prevent readmissions have had mixed success. Understanding heart failure home management through the patient's experience may reframe the readmission "problem" and, ultimately, inform alternative strategies.

OBJECTIVE

To understand patient and caregiver challenges to heart failure home management and perceived reasons for readmission.

DESIGN

Observational qualitative study.

PARTICIPANTS

Heart failure patients were recruited from two hospitals and included those who were hospitalized for heart failure at least twice within 30 days and those who had been recently discharged after their first heart failure admission.

APPROACH

Open-ended, semi-structured interviews. Conclusions vetted using focus groups.

KEY RESULTS

Semi-structured interviews with 31 patients revealed a combination of physical and socio-emotional influences on patients' home heart failure management. Major themes identified were home management as a struggle between adherence and adaptation, and hospital readmission as a rational choice in response to distressing symptoms. Patients identified uncertainty regarding recommendations, caused by unclear instructions and temporal incongruence between behavior and symptom onset. This uncertainty impaired their competence in making routine management decisions, resulting in a cycle of limit testing and decreasing adherence. Patients reported experiencing hopelessness and frustration in response to perceiving a deteriorating functional status. This led some to a cycle of despair characterized by worsening adherence and negative emotions. As these cycles progressed and distressing symptoms worsened, patients viewed the hospital as the safest place for recovery and not a "negative" outcome.

CONCLUSION

Cycles of limit testing and despair represent important patient-centered struggles in managing heart failure. The resulting distress and fear make readmission a rational choice for patients rather than a negative outcome. Interventions (e.g., palliative care) that focus on methods to address these patient-centered factors should be further studied rather than methods to reduce hospital readmissions.

Incorporating patient-centered factors into heart failure readmission risk prediction: A mixed-methods study

BACKGROUND

Capturing and incorporating patient-centered factors into 30-day readmission risk prediction after hospitalized heart failure (HF) could improve the modest performance of current models.

METHODS

Using a mixed-methods approach, we developed a patient-centered survey and evaluated the additional predictive utility of the survey compared to a traditional readmission risk model (the Krumholz et al. model). Area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow goodness-of-fit statistic quantified the performance of both models. We measured the amount of model improvement with the addition of patient-centered factors to the Krumholz et al. model with the integrated discrimination improvement (IDI). In an exploratory analysis, we used hierarchical clustering algorithms to identify groups with similar survey responses and tested for differences between clusters using standard descriptive statistics.

RESULTS

From 3/24/2014 to 3/12/2015, 183 patients hospitalized with HF were enrolled from an urban, academic health system and followed for 30days after discharge. The Krumholz et al. plus patient-centered factors model had similar-to-slightly lower performance (AUC [95%CI]:0.62 [0.52, 0.71]; goodness-of-fit P=.10) than the Krumholz et al. model (AUC [95%CI]:0.66 [0.57, 0.76]; goodness-of-fit P=.19). The IDI (95%CI) was 0.003 (-0.014,0.020). We identified three patient clusters based on patient-centered survey responses. The clusters differed with respect to gender, self-rated health, employment status, and prior hospitalization frequency (all P<.05).

CONCLUSIONS

The addition of patient-centered factors did not improve 30-day readmission model performance. Rather than designing interventions based on predicted readmission risk, tailoring interventions to all patients, based on their characteristics, could inform the design of targeted, readmission reduction strategies.

Projected Costs of Informal Caregiving for Cardiovascular Disease: 2015 to 2035: A Policy Statement From the American Heart Association

Introduction:

In a recent report, the American Heart Association estimated that medical costs and productivity losses of cardiovascular disease (CVD) are expected to grow from $555 billion in 2015 to $1.1 trillion in 2035. Although the burden is significant, the estimate does not include the costs of family, informal, or unpaid caregiving provided to patients with CVD. In this analysis, we estimated projections of costs of informal caregiving attributable to CVD for 2015 to 2035.

Methods:

We used data from the 2014 Health and Retirement Survey to estimate hours of informal caregiving for individuals with CVD by age/sex/race using a zero-inflated binomial model and controlling for sociodemographic factors and health conditions. Costs of informal caregiving were estimated separately for hypertension, coronary heart disease, heart failure, stroke, and other heart disease. We analyzed data from a nationally representative sample of 16 731 noninstitutionalized adults ≥54 years of age. The value of caregiving hours was monetized by the use of home health aide workers’ wages. The per-person costs were multiplied by census population counts to estimate nation-level costs and to be consistent with other American Heart Association analyses of burden of CVD, and the costs were projected from 2015 through 2035, assuming that within each age/sex/racial group, CVD prevalence and caregiving hours remain constant.

Results:

The costs of informal caregiving for patients with CVD were estimated to be $61 billion in 2015 and are projected to increase to $128 billion in 2035. Costs of informal caregiving of patients with stroke constitute more than half of the total costs of CVD informal caregiving ($31 billion in 2015 and $66 billion in 2035). By age, costs are the highest among those 65 to 79 years of age in 2015 but are expected to be surpassed by costs among those ≥80 years of age by 2035. Costs of informal caregiving for patients with CVD represent an additional 11% of medical and productivity costs attributable to CVD.

Conclusions:

The burden of informal caregiving for patients with CVD is significant; accounting for these costs increases total CVD costs to $616 billion in 2015 and $1.2 trillion in 2035. These estimates have important research and policy implications, and they may be used to guide policy development to reduce the burden of CVD on patients and their caregivers.

A qualitative investigation of healthcare workers' strategies in response to readmissions

BACKGROUND

Readmission of a patient to a hospital is typically associated with significant clinical changes in the patient's condition, but it is unknown how healthcare workers modify their provision of care when considering these changes. The purpose of the present study was to determine how healthcare workers shift their care strategies when treating readmitted patients.

METHODS

A typical case sampling study of healthcare workers was conducted using the grounded theory approach. The study setting comprised several patient care units at an academic center and tertiary-care hospital. We purposively sampled 34 healthcare workers (19 women, 15 men) to participate in individual interviews, either face-to-face or by telephone. We asked the participants semi structured questions regarding their thoughts on readmissions and how they altered their process and behavior for readmitted patients. Interviews were audio-recorded and transcribed. We used a qualitative data analyses based on an inductive approach to generate themes about how healthcare workers shift their strategies for readmitted patients.

RESULTS

Healthcare workers' shifts in strategy for readmissions were reflected in three major themes: clinical assessment, use and management of information, and communication patterns. Participants reported that they became more conservative in their assessment of the clinical condition of a readmitted patient. The participants also indicated that readmitted patients would be treated in a similar way to normal admission based on care requirements; however, somewhat paradoxically, they also expressed that having access to prior patient information changed the way they treated a readmitted patient.

CONCLUSIONS

Although healthcare workers may exhibit a tendency to become more conservative with readmissions, readily available patient information from the previous admission played a large part in guiding their thinking. A more conservative approach with a readmitted patient, on its own, does not necessarily lead to improved documentation or better patient care.

Processes and Outcomes of Congestive Heart Failure Care by Different Types of Primary Care Models

BACKGROUND

Having nurse practitioners (NPs) as primary care providers for patients with congestive heart failure (CHF) is 1 way to address the growing shortage of primary care physicians (PCPs).

METHODS AND RESULTS

We used inverse probability of treatment weighted with propensity score to examine the processes and outcomes of care for patients under 3 care models. Approximately 72.9%, 0.8%, and 26.3% of CHF patients received care under the PCP model, the NP model, and the shared care model, respectively. Patients under the NP or shared care models were more likely than those under the PCP model to be referred to cardiologists (odds ratio 1.35, 95% confidence interval 1.32-1.37; odds ratio  1.32, 95% confidence interval 1.30-1.35) and to get guideline-recommended medications. NPs and PCPs had similar rates of emergency room (ER) visits and Medicare spending after adjusting for processes of care. Patients under the shared care model had a higher burden of comorbidity and experienced a higher rate of ER visits and hospitalizations than those under the PCP model.

CONCLUSION

The delivery of CHF care mirrors the severity of comorbidity in these patients. The high rate of hospitalization and ER visits in the shared care model underscores the need to design and implement more effective chronic disease management and integrated care programs.

From discharge to readmission: Understanding the process from the patient perspective

BACKGROUND

Patient engagement is critical in delivering high-quality care. However, literature investigating patient perspectives on readmissions is lacking.

OBJECTIVES

To understand patients' beliefs and attitudes about 30-day readmissions and to elucidate areas for improvement aimed at reducing readmissions.

DESIGN

In person survey.

SETTING

Academic medical center and affiliated community hospital.

PATIENTS

Patients with 30-day readmissions to medicine and cardiology services.

MEASUREMENTS

Patient readiness, attitudes toward readmissions, discharge instructions, ambulatory resources, and follow-up care.

RESULTS

Of 479 eligible patients approached for interviews, 230 (48%) were interviewed. Of these, 28% reported not feeling ready for discharge, and this correlated with inadequate symptom resolution, poor pain control, and concerns about self-care. Sixty-five percent remembered reviewing discharge paperwork, but over 22% could not identify critical information on this paperwork. Eighty-five percent reported having a primary doctor; however, only 56% of patients who received a contact number on discharge called a physician before returning to the hospital. One-third of patients knew where to obtain same-day care outside of the emergency room. Lastly, patients reported feeling more relieved than burdened upon readmission (7.7 [standard deviation {SD} 2.8) vs 5.9 [SD 3.4]; P < 0.001, scale of 1-10).

CONCLUSIONS

By engaging readmitted patients we have illuminated areas for future interventions, including better symptom management and self-care planning before discharge, more clarity in discharge instructions, promoting awareness of outpatient resources, and improved alignment of patient and provider attitudes about readmissions. As the United States strives to reduce readmissions, attending to the patient perspective is critical in informing appropriate avenues for quality improvement. Journal of Hospital Medicine 2016;11:407-412. © 2016 Society of Hospital Medicine.